Information Collection

Original Cohort Forms

IC 7259 under ICR 201309-0925-008 · OMB 0925-0216.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0925-0216 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form A7a Original Cohort Forms	Form and Instruction
A7a Telephone Call to Set up Meeting Attachment 7a- Telephone Contact.pdf	Form and Instruction
A4 Medical Status Update Form Attachment 4 - Medical Hx Update Form.pdf	Form and Instruction
A7b Exam Scheduling Form Attachment 7b- Exam Scheduling.pdf	Form and Instruction
A2a Clinical Exam Form -Original Attachment 2a - Clinic Exam, Original.pdf	Form and Instruction
A6a Records Request Form Attachment 6a- Records Request.pdf	Form and Instruction
A2b Home Visit form-Original Attachment 2b- Home Visit, Original.pdf	Form and Instruction
A6b Informant Contact Form Attachment 6b- Informant Contact.pdf	Form and Instruction

IC Title:

Original Cohort Forms

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	A7a	Telephone Call to Set up Meeting	Attachment 7a- Telephone Contact.pdf	Yes	Yes	Paper Only
Form and Instruction	A4	Medical Status Update Form	Attachment 4 - Medical Hx Update Form.pdf	Yes	Yes	Paper Only
Form and Instruction	A7b	Exam Scheduling Form	Attachment 7b- Exam Scheduling.pdf	Yes	Yes	Paper Only
Form and Instruction	A2a	Clinical Exam Form -Original	Attachment 2a - Clinic Exam, Original.pdf	Yes	Yes	Paper Only
Form and Instruction	A6a	Records Request Form	Attachment 6a- Records Request.pdf	Yes	Yes	Paper Only
Form and Instruction	A2b	Home Visit form-Original	Attachment 2b- Home Visit, Original.pdf	Yes	Yes	Paper Only
Form and Instruction	A6b	Informant Contact Form	Attachment 6b- Informant Contact.pdf	Yes	Yes	Paper Only

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 135

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	135	-4,326	4,461
Annual IC Time Burden (Hours)	131	-4,311	4,442
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.